<table   cellpadding=0 cellspacing=0 border="0" width=700>
	<tr  valign="top">
	<td bgcolor="$bgc1"  class=fva2_ml10><div   class=fva2_ml10>
         $LDRequestTo  <br>
		<font size=3>$formtitle &nbsp $LDDepartment</font>
		<p>
		$TP_checkbox_1 &nbsp; $LDVisitRequested <p>

		$TP_checkbox_2 &nbsp; $LDPatCanBeOrdered <p>
	
		<font size=1 color="#000099" face="verdana,arial">$batch_nr</font>&nbsp;<br>
        $TP_img_barcode
		
	</td>
	<td  bgcolor="$bgc1"  align="right"><div class=fva2b_ml10> $TP_img_patient_label	</div></td>
	</tr>
	
	<tr bgcolor="$bgc1">
		<td colspan=2><div class=fva2_ml10>  $LDDiagnosesInquiries  <br>
		$TP_vspacer_1
		  <font face="courier" size=2 color="#000000">
		  <$TP_block_1> $TP_diagnosis_quiry </$TP_block_1><p>
		  </font>
		</td>
	</tr>	

	<tr bgcolor="$bgc1" valign="top">
		<td ><div class=fva2_ml10><font color="#000099">
		 $LDDate  :
		 <font face="courier" size=2 color="#000000">
		$TP_send_date
		$TP_calender_1
		</font>
  </div></td>
		<td align="right"><div class=fva2_ml10><font color="#000099">
		  $LDDoctor  
		<font face="courier" size=2 color="#000000">
		<$TP_input_1 type="text" name="send_doctor" size=40 maxlength=40 value="$TP_send_doctor">
		$TP_send_doctor_x  &nbsp;&nbsp;&nbsp;&nbsp;
		</font>
  </div></td>
</tr>

	<tr bgcolor="$bgc1">
		<td colspan=2>
		<div class=fva2_ml10>&nbsp;<br><font color="#000099">  $LDDeptReport  <br>
		$TP_vspacer_2
		<$TP_block_2 name="result" cols=80 rows=10 wrap="physical">$TP_result</$TP_block_2>
		</div><br>
				</td>
		</tr>	

	<tr bgcolor="$bgc1">
		<td ><div class=fva2_ml10><font color="#000099">
		$LDDate  :
		$TP_report_date
		$TP_calendar_2
  </div></td>
			<td align="right"><div class=fva2_ml10><font color="#000099">
		  $LDDoctor  
		<$TP_input_2 type="text" name="result_doctor" size=40 maxlength=40 value="$TP_result_doctor">
		$TP_result_doctor_x &nbsp;&nbsp;&nbsp;&nbsp;
  </div></td>
</tr>
</table>
